Gastric transposition in children--a 21-year experience
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Lewis Spitz1, Edward Kiely, Agostino Pierro
1Great Ormond Street Hospital for Children, London England, UK.
Insights
Gastric transposition is an effective esophageal substitution for children, with over 90% good outcomes. This procedure shows long-term function and compares favorably to alternatives despite a 5% mortality rate.
Area of Science:
- Pediatric Surgery
- Gastroenterology
- Thoracic Surgery
Background:
- Esophageal atresia, caustic injury, and peptic strictures are common indications for esophageal replacement in children.
- Many pediatric patients require esophageal substitution due to failed previous repairs, necessitating evaluation of alternative surgical techniques.
Purpose of the Study:
- To analyze the long-term outcomes of gastric transposition in 173 children who underwent the procedure since 1981.
- To assess the efficacy and safety of gastric transposition as an esophageal substitute in a pediatric population.
Main Methods:
- Esophageal replacement via gastric transposition in 173 children (age 7 days to 17 years).
- Procedures included blunt mediastinal dissection (90 patients) and lateral thoracotomy (81 patients).
- Patients were referred from both domestic and international hospitals, highlighting the procedure's broad application.
Main Results:
- No graft failures were observed, even in patients with prior failed operations.
- Anastomotic leakage occurred in 12% of cases, with most resolving spontaneously.
- Anastomotic stricture requiring dilatation occurred in 19.6%, particularly in patients with prior caustic injury.
- Overall mortality was 5.2% (9 deaths), with 90% of patients experiencing good to excellent outcomes regarding swallowing and gastrointestinal function.
- Long-term follow-up showed no deterioration in gastric transposition function, even after 10 years.
Conclusions:
- Gastric transposition is an acceptable and effective procedure for pediatric esophageal substitution.
- The procedure is associated with a 5% mortality rate and a 12% anastomotic leak rate, with 19.6% requiring dilatation for stricture.
- Gastric transposition demonstrates favorable long-term functional outcomes compared to alternative esophageal replacement methods.
Purpose:
The purpose of this study was to analyze the outcome in 173 children (104 M, 69 F) undergoing transposition since 1981.
Methods:
The most common indications for esophageal replacement included failed repair of different varieties of esophageal atresia (127), caustic injury (23), and peptic strictures (8). A total of 81% of the patients were referred from other hospitals (50% from other countries). Age at operation ranged from 7 days to 17 years. The gastric transposition was performed using blunt mediastinal dissection only in 90 patients with an additional 81 patients undergoing lateral thoracotomy. The retrosternal position was used in 2 patients.
Results:
There were no graft failures including those who had previously failed gastric tube or Scharlilike operations. Anastomotic leakage occurred in 12% (all but 1 resolved spontaneously). Anastomotic stricture requiring dilatation occurred in 19.6%. Half of these patients had previous caustic esophageal injury. There were 9 deaths in the group (5.2%). One death occurred intraoperatively, 5 in the early postoperative period, and there were 3 late deaths. In more than 90% of our patients, the outcome was considered good to excellent in terms of absence of swallowing difficulties or other gastrointestinal symptoms. Many, however, preferred to eat small frequent meals. Poor outcome was particularly associated with multiple previous attempts at esophageal salvage. There was no deterioration in the function of the gastric transposition in those patients followed up for more than 10 years.
Conclusions:
Gastric transposition for esophageal substitution is an acceptable procedure. It is attended by 5% mortality and a 12% leak rate. A total of 19.6% of the patients needed anastomotic dilatation for stricture. In the long term, good function has been maintained. Gastric transposition compares favorably with alternative methods of esophageal replacement.
